A Realistic Appraisal of Patient Centered Medical Home, Courtesy of the Robert Wood Johnson Foundation

REALLY close look at the PMCH

While supporters of the Patient Centered Medical Home (PCMH) believe it is the greatest thing since the invention of the poultice, realists may appreciate this more evidence-based examination of the topic by Bob Berensen and colleagues, courtesy of the Robert Wood Johnson Foundation.   Among the take-aways for the Disease Management Care Blog:

1.  There is no evidence that the entire suite of services or "principles" provided by a PCMH improve quality or reduce costs.  Rather, only some do.  Research is needed on which combinations produce the greatest value for patients, and which ones can be jettisoned.  We also don't know if it works in all practice settings (for example, in smaller, physician owned practices) and for all types of patients.

2. Current measures of PCMH rely on survey tools that ask about processes of care.  Given the emerging consensus that real goal of primary care is patient centeredness, it's possible that PCMH "recognition" and "accreditation" will become dependent on patient surveys.

3. Estimates of costs to physicians to become PCMHs run from a few thousand to more than a hundred thousand dollars.  In other words, we have no idea.

4. PMCH fee schedules can take a number of forms, including some combination of a) increases in fee-for-service payments, b) coverage for specific services, such as patient coaching, c) monthly lump payments, d) capitation, e) pay-for-performance for outcomes tied to the PCMH,  f) shared savings.

5. While dozens of pilots are underway, the largest is being sponsored by Blue Cross Blue Shield of Michigan.  This is likely to be eclipsed by a "Patient Aligned Care Team" initiative in all of the Veterans Administration's primary care clinics.

6. There are no data on what percentage of primary care physicians believe in the PCMH.  We also don't know how many plan to make the transition to one.  We also don't know if medical students will find the PCMH a compelling reason to go into primary care.

7. Last but not least, many past studies and current pilots are using only some of the PCMH principles, have inexact evaluation plans and many are not using a valid comparator.  It will be difficult to draw any consistent conclusions.

The DMCB will end with this closing quote by Dr. Berensen et al, which reminds it of what happened to the disease management industry.  It could not have said it better itself. Backers of the PCMH ignore this sage advice at their peril:

"The medical home model does have the potential to transform the way health care is delivered – but 'potential' is the key word here. The danger posed by the current enthusiasm for the concept is that it could lead to the adoption of unproven models on a wide scale nationwide before evaluations of existing pilots can show us what works in what situations, and what levels of reimbursement are needed to get providers to engage in all the new activities encompassed by the medical home model. This could lead to a failure to improve quality or save costs, and could result in a good idea being dismissed as ineffective before it has a chance to succeed. Whether we have the patience to nurture and recalibrate the medical home model as evidence comes in from evaluations before jumping to conclusions about its success or failure remains to be seen."